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Foodservice, Health and Nutrition: Responsibility, Strategies and ..... for chain restaurants, there is little regulation worldwide regarding nutrition, either on the.

To be published as: Saulais L. (2015) “Foodservice, Health and Nutrition: Responsibility, Strategies and Perspectives” in The Routledge Handbook of Sustainable Food and Gastronomy, eds. Philip Sloan and Willy Legrand. Routledge. pp.253-266.

Foodservice, Health and Nutrition: Responsibility, Strategies and Perspectives

Laure Saulais Center for Food and Hospitality Research, Institut Paul Bocuse INRA-University of Grenoble, UMR 1215 GAEL

Abstract: As the contribution of meals eaten away-from-home to food intake increases, the health of restaurant customers becomes a new responsibility of the foodservice sector. This chapter provides an overview of the main strategies that the foodservice sector can implement in order to improve the nutritional quality of meals consumed away from home. Complementary actions can be undertaken at the supply and at the demand level. At the supply level, professionals can change recipes and cooking methods to offer healthier dishes. At the demand level, two types of strategies can be implemented to guide consumers’ behaviours. Information-based strategies aim to provide nutrition information, either through general campaigns or directly at the point of choice; while behavioural strategies are based on the way options are displayed at the point of choice. Information-based strategies generally have positive impacts on attitudes and intentions to eat healthy, but their direct impact on behaviours is difficult to demonstrate. Conversely, behavioural strategies show promising results on behaviours, but their impact still remains insufficiently documented. We end this overview by discussing motivational and practical barriers to the successful implementation of such strategies in away-fromhome contexts.

Keywords: nutrition, foodservice, choice architecture, labels, nutritional information

Introduction For the foodservice sector, whose mission is to provide meals outside the home, the health of consumers is becoming a new responsibility – and a new challenge. The alarming rise of chronic diseases associated with nutritional imbalance is a collective concern worldwide. Overweight or obese people amounted to 47.3% of French adults in 2012 (INSERM et al. 2012) and 68% of American adults in 2007-2008 (Flegal et al. 2010)1. The foodservice sector has been blamed for its role in the obesity epidemics, with quick-service restaurants in the front line (Lake & Townshend 2006; Prentice & Jebb 2003). One of the difficulties in assessing the contribution of foodservice to this phenomenon, however, lies in the variety of activities covered by this industry2 and, in particular, the heterogeneity of the offer –from sandwiches to gastronomy. However, there is a general

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Adults were aged 18 or over for the French figures, 20 or over for the USA. The definition of the scope of activity of the foodservice sector, in itself, is debated (Edwards 2013), which may substantially affect the evaluation of this contribution. 2

consensus that away-from-home (AFH) foods3 play an important role in the diet (Lachat et al. 2012), with a variable contribution across countries and age groups. Adults in the US obtain up to 32% of their daily calorie intake from AFH sources (Lin & Morrison 2012). European adults eat between 12 and 28% (depending on country and gender) of their daily calories outside their home (Orfanos et al. 2007). In a context of rapid evolution of eating habits and forms of consumption (Grunert 2013), the number of eating-out occasions is increasing in most countries (Lin et al. 1999; Laisney 2012; Lachat et al. 2012) and, consequently, so does the contribution of AFH food to diet (Martinez-Palou & Rohner-thielen 2011). This trend raises concerns in the public health community, as AFH eating has been associated in many studies with higher energy intake, excessive fat and salt intake, and poorer nutritional quality of the diet (Lachat et al. 2012; Larson & Neumark-Sztainer 2011; Myhre et al. 2013; Park et al. 2009). In other words, eating out more seems to lead to eating more. Other epidemiological studies have directly linked consumption outside the home and body mass index (Naska et al. 2011; Bezerra et al. 2012; Bes-Rastrollo et al. 2010). Some specific characteristics of the AFH food offer have been particularly pointed out in this phenomenon. The first characteristic is the nutritional quality of the food offered: several studies, indeed, report larger portions sizes and a poorer nutritional quality of AFH food (Lin & Morrison 2012; Nielsen & Popkin 2003; Prentice & Jebb 2003). Another characteristic is the context in which the food is offered. A greater availability of energydense foods, a lower availability of healthy options, and a lack of information about the contents of the products, have indeed been highlighted (Lachat et al. 2009; Lachat et al. 2012). Obesity is a multifactorial problem, and preventing it requires to combine multiple levels and scales of action. Interventions may target the offer itself, the context, but also consumers and their behaviors. Actions may be undertaken on a large scale (e.g. with health education programs), or locally, with actions at the point of choice. At the restaurant scale, improving the nutritional quality of meals consumed by restaurant customers can be achieved either by changing the offer, or by guiding consumers’ choices. The rest of this chapter discusses these approaches and the possible barriers to the implementation of such actions.

On the supply side: offering healthier options Eating meals prepared out of home makes it more difficult for consumers to control the nutritional content of dishes, and, therefore to eat healthy (Lachat et al. 2009). For foodservice professionals, two levels of actions can be considered when looking at the challenge of offering healthier meal options: the dish level (i.e. modifying the recipe, for instance by substituting saturated fat for unsaturated fats, by reducing sugar content or adding dietary fibres) and the assortment level (i.e. offering smaller portions, or adding to the menu healthier options that were previously unavailable, for instance increasing the number of fruits on offer for dessert).

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Lin and Frazao (1999) propose to distinguish home and away-from-home foods on the basis of the location where they are obtained (as opposed to where they are eaten): away-from-home (AFH) foods covers any food prepared outside the home and consumed without any additional culinary preparation by the consumer, whether it is consumed outside the home, in a restaurant, or at home (Lin et al. 1999).

For instance, in the “Better Life Menu” program in Canada, recipes of usual dishes were modified to contain a maximum of 30% energy from fat (10% from saturated fat), and polyunsaturated or monounsaturated fats were used for sauces, salad dressings, and cooking. This dish-level intervention was coupled with assortment-level changes, such as an increased availability of lower-fat products and a decrease in portion sizes. Regular customers of a worksite cafeteria decreased their saturated fat and protein intake by 3%, while carbohydrate intake increased by 7% of total energy (Dubois et al. 1996). The reference to define healthy food is generally official nutritional standards. In an effort to translate these standards into actions for foodservice professionals, the European FOOD program4 developed a guide providing simple advice, such as preferring steam cooking to frying, or seasoning with spices rather than salt. Quantifying the direct nutritional impact of offer modification is difficult. Because of the variety of foodservice activities, and the diversity of actions, meta-analyses are limited. Nevertheless, a recent review of six studies in workplace restaurants, found some (though limited) evidence of a weak but positive behavioural effect of such interventions (alone or combined with nutrition education). Improvements concerned mainly fruit and vegetable consumption (Geaney et al. 2013). Strategically, improving the offer can be an added-value for foodservice companies, who may communicate about their commitments. In 2013, the major European quick-service restaurant company Quick publicly announced5 the signature of a charter with the French Health Ministry6, with commitments to improve the dietary quality of its offer.

On the demand side: changing food choices behaviours While an essential step towards the improvement of meals, changing the offer is a ‘one size fits all’ approach. Restaurant customers, on the other hand, have varied nutritional needs, but also varied motives for having a meal, and different representations and knowledge regarding healthy eating. Another approach to improving the quality of the meals eaten by restaurant customers is to help them make better choices for themselves amongst a variety of options, either by providing information to consumers, or by changing the way food options are presented.

Information-based strategies 4

The FOOD (Fighting Obesity through Offer and Demand) project (2009-2011) was a multi-partner project which received funding from the European Union, in the framework of the Public Health Program. 5 June 3rd, 2013 Press Release: “Quick, 1ère enseigne de restauration rapide à signer une « Charte d'engagements volontaires de progrès nutritionnel » avec les Pouvoirs Publics“ http://groupe.quick.fr/fr/une-histoire-degout/quick-1ere-enseigne-de-restauration-rapide-signer-une-charte-dengagements-volon (last accessed Nov 8th, 2013) 6 The French program for Nutrition and Health (PNNS) has set up charters (Chartes d’engagements volontaires de progrès nutritionnel), which are signed on a voluntary basis by food or foodservice companies committing themselves to improve the nutritional quality of their offer. The Quick charter signed in 2013 can be found on the website of the Health Ministry : http://www.sante.gouv.fr/IMG/pdf/Quick.pdf (last accessed Nov.8th, 2013). Four axes of improvement were defined: fat, sugar, salt and fibres. Examples of commitments found in the charter are the increase from 15% to over 50% of the dietary fibres content in breads utilized for the burgers, or the reduction of sugar content in sodas by 100%.

Providing information to consumers is probably the most widespread approach for healthy AFH eating. These information-based strategies rely on the assumption that informing consumers allows them to make better choices. Different approaches are possible, as summarized below (Figure 1). Actions are differentiated in terms of the nature of the information diffused (they either provide consumers with general knowledge and recommendations about healthy eating, or display specific information about the products on offer), and in terms of means of diffusion (information is most commonly displayed at the point of choice, but may also appear outside the restaurant). Outside the eating location, the development of the internet has allowed the emergence of new vectors of information. Major quick-service restaurant chains such as McDonald’s or Kentucky Fried Chicken provide nutritional information on their products on their websites. In 2013, McDonald’s also started implementing QR codes on packaging, that direct consumers to the nutritional values of the dish7. Augmented reality should also, in the near future, open new opportunities for providing customized product information.

Type of information General information : knowledge and reminders, recommendations •Composition of a balanced diet •Healthy lifestyle...

Product-specific information: •Calories : per portion , per 100g... •Nutrients •% GDA

Display and diffusion method

On the products / dishes (labels, menu information) In the restaurant (but not on specific products): posters, leaflets, brochures, table tents. Outside the restaurant (consumer has to go looking for information) : internet website, apps

Figure 1: A typology of information-based strategies in foodservice settings (Source: The author)

General information The objectives of such programs are generally defined in the long term. They aim to educate consumers about nutrition, to remind them of healthy practices and/or to improve knowledge and awareness of the importance and conditions of healthy eating, in the hope of changing attitudes and intentions, and, eventually, behaviours. They may combine several types of tools (eg. Training, information, coaching...) and be deployed in different locations (beyond the point of choice and consumption). 7

Johnson, L. (2013) QSRs' appetite for QR codes shows no signs of waning , Mobile Marketer, July 29th, 2013. URL: http://www.mobilemarketer.com/cms/news/software-technology/15835.html page accessed Nov 5th, 2013.

While education and awareness raising are not the primary missions of the foodservice sector, restaurants can be good settings for such programs. This holds especially true when customers are regular, allowing for longer exposure to messages. Since these programs primarily target knowledge and satisfaction, only a few studies have assessed their direct impact on food intake or choices, with non-significant, weak, or partial effects (Fitzgerald et al. 2004; Steenhuis et al. 2004). Conversely, the impact on customer attitudes, awareness and satisfaction is generally positive. For instance, the TrEAT Yourself Well social marketing campaign targeted restaurant diners in California through media advertising, on-site promotion and various community events. A survey demonstrated a positive effect on beliefs and attitudes towards healthy eating (Acharya et al. 2006). Because of this seemingly low direct impact on behaviors, general information is often combined with other actions and different levels of information, mixing, for instance, information on nutrition, physical activity, and nutritional content (Sorensen et al. 1992; Holdsworth et al. 2000). Because of this multi-component approach, these programs may be quite costly to implement. The heterogeneity of approaches also makes the assessment of their efficiency quite difficult.

Product-specific information Most of the time referred to as “calorie posting” or “nutrition labelling”, product-specific information strategies consist in providing descriptive, factual information on the nutritional contents of the dishes or products sold. Unlike in the packaged foods sector8, this practice is recent in the foodservice sector. Mandatory calorie labeling was only extended to chain restaurants in New York City in 2008, and in all US chain restaurants in 20109. In Europe, voluntary initiatives have recently emerged –notably in the major quick-service restaurant chains. Scientific evaluations of the nutritional impact of such actions have had mixed results, depending on the type of restaurant, the target population, and the duration of the intervention (Harnack & French 2008; Holdsworth & Haslam 1998; Seymour et al. 2004). Several studies also find the success of such operations to depend upon the initial motivation of participants to eat healthier (Harnack et al. 2008; Dumanovsky et al. 2011). Much like general information, nutritional information generally improves customer satisfaction, attitudes towards nutrition and calorie information, perceived benefit of the program and perceived usefulness of the information. However, it should be noted that this has only been measured in US populations. Whether the same effects would be observed 8

Packaged foods sold in retail have been subjected to mandatory labelling in many countries for several years (Hawkes 2004). In the USA, “nutrition facts” have been mandatory for packaged foods since 1990. 9

According to the Patient Protection and Affordable Health Care Act, US chain restaurants with over twenty locations must disclose calorie information for standard menu items and make nutrient information available on demand. (HR- 3590 Patient Protection and Affordable Health Care Act - Sec. 4205: Nutrition Labeling of Standard Menu Items at Chain Restaurants. 2010. United States of America: 111th Congress of the USA. http://www.govtrack.us/congress/bills/111/hr3590/text.)

elsewhere, with different dietary practices and knowledge about nutrition, remains largely unknown. Lastly, while providing information to customers appears to increase their satisfaction, it is unclear whether this information is actually used to make choices, or if consumers simply value information.

Choice architecture Information-based strategies rely on the premise that consumers call upon rationality to make decisions. Thus, providing information to consumers should improve the quality of their decisions. This assumption is challenged by recent advances in behavioural sciences, which provide evidence that the environment of choice, or the way the choice task is structured (called the “architecture of choice”) also affects decisions. Since the works of Kahneman and Tversky on dual-process reasoning systems (Kahneman 2003; Tversky & Kahneman 1974; Tversky & Kahneman 1986; Tversky & Kahneman 1981), it has been hypothesized that rationality is bounded, and that decisions are subjected to biases. Decisions involve two systems of reasoning: a fast and automatic system (system 1) which relies on emotions and intuition, and a slow and reflexive system (system 2) which relies more heavily on thinking and rationality (Kahneman 2011). Food choices involve intuitions and emotions, and may thus rely on system 1 (Köster 2009). They may also be biased in an automatic way by the context of choice. As these biases are predictable, the environment can be manipulated to orient consumers towards choices considered as healthier (Ariely 2009). Approaches using changes in the choice environment, popularized under the term "nudge" since the works of Thaler and Sunstein (Thaler & Sunstein 2008), have recently generated considerable interest from the Public Health sector. Specific government departments, such as the British behavioural insights team (referred to as the “Nudge Unit”), were created in the USA and the UK in order to explore such avenues for public action. In the foodservice sector, some experiments were conducted to test the effect of environmental changes on the nutritional quality of meals, with promising results (Downs et al. 2009). “Nudging” restaurant customers towards healthier choices in AFH settings can take many forms. Using the MINDSPACE framework (Dolan et al. 2012), Figure 2 presents examples of successful nudges tested in AFH settings. One of the most frequently encountered approaches is the use of labels to signal healthy items on menus (or in a cafeteria display line) to simplify the information-processing task performed by consumers. Nutrients and calories are factual indicators, but restaurant customers eat dishes, not nutrients. Therefore, they may not be able to process information at the nutrient level, especially since dishes may contain both healthy and unhealthy nutrients. By placing the focus on a single attribute, labels reduce the parameters of the decision. They also “prime” consumers with unconscious cues. Labels are often displayed with accompanying posters, which describe the program. While the criteria of selection for labelled items vary, they most frequently target low-fat products, or products that are rich in dietary fibres. The intervention may consist either in labelling already existing products, or in developing new dishes meeting the criteria. It is however unclear whether these actions have beneficial effects on consumer choices. Sales of labelled items increase, in most studies, for at least a subset of the targeted offer. However, the impact on actual individual food intake is unclear (Dubbert et al. 1984; Steenhuis et al. 2004; Hoefkens et al. 2011).

Figure 2: Examples of successful nudges in AFH settings (Source: The Author)

Creating incentives

Using defaults

Committing

Using saliency

• Giving rewards for choosing healthy items (Mayer et al. 1987) • Price reductions for healthy items (French et al. 1997) • Changing price metrics: discounts on flat-rate pricing (Just & Wansink 2011), valuesize pricing

• Changing defaults to healthy items on menus (McCluskey et al. 2012) • Default payment method: using a prepaid card for healthy items (Just et al. 2008).

• Pre-selected meals: Preselecting foods on a menu prior to the meal (Just et al. 2008)

• Increasing the availability of healthy options (French et al. 2004). • Increasing the visibility/ access to healthy food (Rozin et al. 2011). • Attribute parcimony : Labeling healthy items or both healthy and unhealthy items (Levy et al. 2012)

Structuring the choice task • Menu Design: changing item position on the menu (Dayan & Bar-Hillel 2011). • Increasing variety and choice of healthy foods (Domínguez et al. 2013).

Priming • Reducing portion sizes (Freedman & Brochado 2010). • Increasing convenience with pre-sliced fruits (Wansink et al. 2013) • Changing serving sizes or ustensils (Rozin et al. 2011)

Using norms and messengers • Peer modeling :Showing videos of heroic characters (Food Dudes) promoting healthy foods (Horne et al. 2009)

Nudges are promising. From an operational point of view, they seem relatively straightforward and inexpensive to implement. Yet, to our knowledge, their actual monetary cost has never been evaluated. Furthermore, at this point, data is insufficient to demonstrate their effectiveness and their applicability to a variety of AFH contexts and populations. However, some robust effects can be drawn from experiments in other Public Health fields (Dolan et al. 2012). Further research should therefore be carried out in order, firstly, to strengthen the existing data on the effectiveness of such approaches in AFH settings and secondly, to enable their operational development in the foodservice sector. In particular, the menu card is the main medium of choice at the restaurant, and thus embodies both a critical point of the choice architecture and an apparently simple way to explore the operational level. An experiment showed, for instance, a link between the menu position of an item and its sales (Dayan & Bar-Hillel 2011). Other behavioural levers, identified and tested in other areas of public health (Blumenthal-Barby & Burroughs 2012; Johnson et al. 2012; Thaler et al. 2010) could be explored in the design of menu cards promoting healthiest choices. For example, the menu categories (usually structured as "appetizers, main dish, dessert") could be modified to guide towards healthy choices, using research on partitioning and variety-seeking behaviours which shows that consumers tend to evenly allocate their choices within a set of categories (Johnson et al. 2012; Read et al. 1999).

Diffusion The diffusion of nutritional strategies within the foodservice sector is very heterogeneous. In France, major companies are the most active. All major collective catering companies have developed nutrition and health programs in the past decade (such as Sodexo’s Programme Equilibre, launched in 2003, which became the Boost&Moi program in 2012, or the Démarche Equilibre by Elior, started in 2004). These programs rely on a multitude of tools

acting both on the quality of the offer and diffusion of information to consumers (through brochures, posters, animations etc.). Some of the tools and messages of these programs have obtained a certification from the National Health and Nutrition Program (PNNS). The fast food industry, meanwhile, has started to display product-specific information: for example, McDonalds France provides the energy values of some sandwiches, and has a website where customers can view their energy needs and calculate the nutrient and energy contents of their meals. In traditional commercial catering, conversely, whether chain or independent, initiatives remain scarce. The existence of a legal framework, and its nature, determine partly the level of involvement of foodservice actors, and institutional and commercial foodservice are affected differently by regulations. In France for instance, as soon as 2001, official recommendations were established by the GEMRCN10 for institutional foodservice. In 2010, a statutory obligation was introduced for the implementation of nutritional recommendations for institutional meals in schools, university, kindergartens, health care institutions, social and medico-social institutions and prisons11. Similarly, voluntary standards became statutory in England for schools in 2008, and should be implemented in the four UK countries by September 2013 (Adamson et al. 2013). The existence of a framework does not, however, fully guarantee the implementation of related actions. Obligations may be perceived as frustrating or confusing by foodservice professionals (Almanza et al. 1997), slowing down their implementation. In France, a debate regarding the obligation to apply nutrition standards in collective catering settings has opposed, in 2013, Public Health actors with operators arguing that standards were too difficult to meet (Société Française de Santé Publique 2013). Regarding commercial foodservice, with the exception of the recent US regulations for chain restaurants, there is little regulation worldwide regarding nutrition, either on the nature of the offer or on the information provided to consumers. The impulse to change may thus rely for a large part on voluntary commitment from the foodservice sector. Indeed, most of the programs described in this chapter were developed primarily for commercial purposes, in response to consumer demand for a healthier food offer, for more information or, in the case of contract catering, as an asset in business-tobusiness negotiation. Consequently, the success of the programs in actually improving diets is generally a secondary objective, which is not systematically evaluated.

Barriers to improving nutritional quality in foodservice A few studies have shed some light on potential obstacles to implementation of nutrition actions, which may also explain the limited development of such programs, especially in independent restaurants.

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The acronym GEM-RCN stands for « Groupe d'étude des marchés de restauration collective et nutrition » (Study group on the markets for Public Catering and nutrition). This study group defined recommendations for the composition and structure of institutionalized meals (e.g. standards regarding the frequency of some dishes in the menu, the quantities and portion sizes…). 11 An application decree (Décret n° 2011-1227 du 30 septembre 2011 relatif à la qualité nutritionnelle des repas servis dans le cadre de la restauration scolaire) for this obligation, based on the previously established GEMRCN standards, came into effect for all school food services from September 1st, 2012, followed by other decrees for the other sectors (effective in 2013).

Beliefs and motivation In the absence of legal obligation, foodservice professionals need to be convinced that consumers are looking for balanced meals or that they value nutrition information. Among potentially precluding beliefs about consumers’ expectations, is the assumption that consumers are more attracted to unhealthy food and find, on the contrary, healthy food to be devoid of taste12. Restaurant owners may also have beliefs about the definition of healthy food, which may drive the choice of actions to implement (Vyth et al. 2012).

Lack of nutritional expertise Developing nutrition strategies calls upon an expertise that may not be part of the training of foodservice professionals. For instance, product-specific information labeling requires a nutritional evaluation of the dishes content. While major chains may afford a dietician and the adequate technical capacity for measurement, it may not be the case of independent restaurants. Restaurant-specific challenges may arise such as the frequency of menu renewal, or the lack of structural flexibility for the supply of adequate ingredients (Lachat et al. 2010), which may lead to improper or partial application of nutritional standards. In a recent study in the top 400 US chain restaurants, most main dishes complied to recommendations regarding daily energy needs, but not regarding nutrients, specifically sodium and fat (Wu & Sturm 2012). Lastly, restaurant owners may have trouble following recommendations while trying to address a heterogeneous demand (Vermeer et al. 2010).

Time and human resources A lack of operational feasibility may also slow down the implementation of such programs. Notably, the perceived added workload, the lack of financial resources or time, and more generally the fear of a cost premium related to the program, constitute barriers to the implementation of such procedures (Vyth et al. 2012; Almanza et al. 1997). Facing these obstacles, the main determinants of professional involvement in nutrition programs are that the easiness of implementation of the actions (Vermeer et al. 2010), the adaptation of the measures to the local culture and constraints (Lachat et al. 2010), as well as the possibility to communicate about the implementation (Vyth et al. 2012). The results of the European FOOD program, in which questionnaires were handed out to restaurant owners, corroborate these findings and show that the time and budget, beyond the lack of expertise of Chefs about nutrition, remain, in independent private restaurants in particular, powerful barriers to implement changes to a more balanced diet. These practical barriers to implementation may appear even when there is either motivation (commercial), a framework or even a legal obligation to implement the programs. For instance, a study on the application of GEMRCN recommendations in France reported that secondary state schools complied, on average, with only half of the provided guidelines (Bertin et al. 2011).

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The question of whether such assumptions are founded is debated in the scientific community. Studies about this so-called “Unhealthy = tasty” effect find contradictory results: some authors find that food labelled as ‘less healthy’ are expected by US consumers to be tastier, more enjoyable, and preferred in choice tasks (Raghunathan et al. 2006), while the assumption is not verified by other authors -for instance in the French population (Werle et al. 2012).

Perceived costs and benefits Although a strong determinant of the implementation of nutritional action, the financial impact of such programs - whether positive or negative - is hard to assess. For instance, the implementation of nutritional labeling involves some supplementary costs (nutritional evaluation of dishes, cost of the communication tools, etc.). The resulting benefits of such programs are, however, difficult to ascertain. While most studies report a demand for information and an overall positive effect of such programs on customer satisfaction (Josiam & Foster 2009; Alexander et al. 2010), the direct impact on willingness-to-pay and on demand is unclear and context-dependent. Regarding the cost of changing the quality of the offer, likewise, little evidence is available in the literature. In a study of the implementation of the GEMRCN in French school canteens, Darmon et al. (2010) find that restaurants which had started following the recommendations had reduced their costs, due to the recommended reduction of portion sizes (Darmon et al. 2010). However, the same study revealed that there were no differences in costs between sites applying or not the recommendations at the same time period.

Conclusion Achieving sustainability in foodservice requires taking into account the ecological, economic and social aspects of this activity. One of the key aspects in this equation is to preserve the health of consumers, by ensuring that they can eat healthily. While the strategies described in this chapter could all potentially contribute to this objective, their implementation is not straightforward. On the supply side, the increased awareness of cooks, the growing pressure from the market to produce healthier food, as well as the slow emergence of a regulatory framework may contribute to improving the nutritional quality. However, many barriers, which we described above, exist, and the path to success may not be linear. It has been demonstrated that customers tended to greatly underestimate their calorie consumption in the restaurant (Burton et al. 2006). This result, put into perspective with those on the effect of menu information and phrasing on the judgement and choices of consumers (Wansink et al. 2001; Wansink et al. 2005) seems to support the idea of the appropriateness of nutrition information on menus. But studies directly assessing the effects of point-ofpurchase information on food choices show that these effects depend on context, customer characteristics (especially their motivation), and the nature of the information available. Point-of-purchase information, therefore, may require to be complemented by longerterm health promotion and education programs. Such an approach would go beyond the normal scope of action of the foodservice sector, and require collaborations between foodservice professionals and other actors, such as Public Health professionals. But it may demonstrate more efficiency in the long run. A 2010 review listed sixteen British studies evaluating the effect on nutrition-related variables of interventions to promote health in the workplace. The results indicate a positive, but weak effect on eating behaviours and on the nutritional status of employees. The authors, however, noted the low robustness of the results of available studies, and specifically, the lack of financial and acceptability assessment of interventions (Mhurchu et al. 2010).

Another promising approach is the modification of the choice environment through nudges, which have contributed to highlight the importance of the choice setting on behaviours, and the impact of the strategic choices of foodservice professionals on consumer health. One striking example is the impact of portion sizes and value-size pricing on food choices (Pratt et al. 2007; Vermeer et al. 2009; Freedman & Brochado 2009). However, setting up nudges in a foodservice environment raises the delicate point of how to determine what the “better choices” should be for consumers. This normative aspect of nudges, which has been the topic of much debate in the literature, relates to important ethical questions about the extent to which public health actors, but also foodservice professionals, should intervene in consumers’ food and health-related choices (Blumenthal-Barby 2013; Selinger & Whyte 2011; Quigley 2013). Ultimately, despite the need to strengthen current knowledge about possible actions, there are many ways in which foodservice can an actor of health and nutrition promotion, and a vector of good practices, information and education.

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Author’s Bio Laure Saulais is a research scientist at the Institut Paul Bocuse Food & Hospitality Research Center in Ecully, France, and an associate researcher at the French National Institute for Agricultural Research (INRA) in Grenoble, France. She has a MSc in Food and Life Sciences Engineering from AgroParisTech, a MSc in Environmental and Natural Resources Economics from Paris X University and a PhD in Economics from the University of Grenoble. Before she joined the Institut Paul Bocuse, she was a postdoctoral fellow at Université Laval (Québec, Canada). Since she joined the Institut Paul Bocuse Research Centre in September 2009, she has been taking part in the development of research activities and methodologies, the coordination of projects and the academic activities of the Institut Paul Bocuse. She also teaches courses on experimental economics, and food consumer research in various universities, engineering and business schools in France. Her main area of research is behavioural economics, with a focus on the study of consumer decisions, behaviours and economic preferences related to food in out-of-home contexts. E- mail: [email protected]